Advanced practice and clinical supervision: An exploration of perceived facilitators and barriers in practice

Abstract Aim and Objectives The aim of this study was to investigate current advanced practice Masters students’ experience of clinical supervision, to explore how clinical supervision works in practice and to identify students’ perceptions of the facilitators and barriers to clinical supervision in their workplace. Background Advanced practitioners, and in particular nurses, play a pivotal role in delivering health care across acute and primary care settings. These non‐medical professionals fulfil a rapidly expanding proportion of roles traditionally undertaken by medically qualified staff within the National Health Service in the United Kingdom and often lead specialist clinics and services. To prepare for the advanced practice role, individuals are required to undertake a Master's in advanced practice to develop the required skills and knowledge and work in clinical practice with a clinical assessor/supervisor to demonstrate competence and performance. Design A mixed method study using an online descriptive cross‐sectional survey and qualitative data were collected via focus groups and has been reported using the Good Reporting of a Mixed Methods Study checklist. Results A total of 79 students completed the online survey (from 145 AP students), a response rate of 55%. Most respondents were nurses (n = 73) with 49 (62%) in a formal advanced practice trainee role, and the majority believed their clinical supervisor had a good understanding of advanced practice and the advanced practice role. Two focus groups were held with 16 participants in total. Thematic analysis revealed five themes: (a) perceived level and amount of support from clinical supervisors, (b) skill level of clinical supervisors, (c) physicians and their perceptions on supervising, Advanced practitioners (d) clinical supervisors’ preparation for the role and (e) transition from trainee to qualified advanced practitioner. Conclusion The survey revealed that advanced practitioner students perceived that clinical supervisors and workplace colleagues had a good understanding of the advanced practice role with good levels of support in practice. A more coherent approach is required for clinical supervision and an implementation framework that can be formally evaluated. Relevance to clinical practice Several significant barriers to clinical supervision for advanced practitioner students were identified, and there are currently more barriers (including COVID‐19) than facilitators.

The AP framework aimed to standardise the advanced practitioner role with a clear definition and core capabilities. All registered healthcare professionals should be continuously developing their practice, and so it is anticipated that APs working at advanced level will develop their practice beyond this threshold by working with a suitable clinical supervisor in their workplace.
The role of the clinical supervisor is to provide opportunities for the AP to reflect on and review their clinical practice, discuss individual cases in depth and identify changes or modifications to practice required to maintain professional and public safety. Clinical supervision also provides an opportunity to identify training and continuing development needs (Care Quality Commission (CQC, 2013)). The Royal College of Nursing debated that a fellow registered nurse could undertake the role as a clinical supervisor for the AP, but this view was not supported because the developing AP is more advantaged by working with, and alongside a range of other multi-professionals who have a broader range of skills and higher levels of theoretical knowledge (RCN, 2019).
The expectation is that APs working at advanced level will have achieved this during extensive experience and following completion of master's level education or its equivalent. As such, AP students require clinical supervisors to assess them in their workplace and ensure they are competent in all the core capabilities. Competence is a concept around the AP's knowledge, skills, values and attitudes Relevance to clinical practice: Several significant barriers to clinical supervision for advanced practitioner students were identified, and there are currently more barriers (including COVID-19) than facilitators.

K E Y W O R D S
advanced practitioners, barriers, clinical supervision, facilitators, supervision frameworks What does this paper contribute to the wider global clinical community?
• There is a need for a standardised supervision framework for APs in clinical practice.
• More work is required by employing organisations to recognise the need for protected time for clinical supervision for Aps.
• Formal clinical internship for APs would ensure protected time with a clinical supervisor and offers a structured approach to assessment of learning needs in clinical practice.
• Improved partnership working between healthcare providers and higher education institutions could support formal evaluations of supervision frameworks.
• It will take time for a body of APs to be trained as supervisors, so in the meantime supervisor, training for medical practitioners is recommended as part of their continuous professional development. (Raleigh & Allan, 2017). A recently released report noted that there is wide variation in the establishment of APs and current supervision practices are usually profession-specific with some supervision across the traditional professional boundaries (HEE, 2020). This report also proposes that clinical supervision is perhaps best led by the trainee AP because their learning needs are individualised, and they may require different supervisors at different points in their development journey (HEE, 2020). Nevertheless, a structure to guide the supervision process has been proposed (HEE, 2020), whereby trainee APs should identify a suitable assessor within their work environment. The assessor should.
• Have a good understanding of the advanced practice role Many of the papers on AP focused on the transition from trainee to qualified practitioner (Dover et al., 2019;Murphy & Mortimore, 2020). A recent study in primary care applied a 'hub and spoke' approach as an alternative to traditional supervision methods in primary care. This process used the strengths of both the General Practitioner (GP) and the AP (Gloster et al., 2020). The 'hub and spoke' primary care model is an organisation where a main wellresourced hub is established that supplies intensive medical services and is complemented by satellite campuses/spokes. In the findings of their qualitative analysis, it was noted that trainee ACPs highly valued consistent clinical support from a range of designated GP supervisors and peers afforded by the 'hub and spoke' model, because they worked across different practice boundaries (Gloster et al., 2020). Trainee ACPs experienced better levels of clinical supervision when GP supervisors understood supervision requirements, and the vision of the trainee ACP role in primary care (Gloster et al., 2020). The AP NHS England Framework introduced capabilities as part of the AP Masters programmes and as such, students must be assessed in their clinical workplace and deemed competent in all areas (HEE, 2017).
In our institution, students are required to identify a suitable clinical supervisor who is willing to support and assess them in practice using the AP framework document and using the King's Performance Rating Criteria, so the clinical supervisor can document the level students are working at (Fitzpatrick et al., 1997). This scale allows students and supervisors to identify the areas of independent practice and those of a supervised, assisted and dependent level of practice. The amount and level of clinical supervision have not been quantified, and there is no information available on the barriers and facilitators to clinical supervision or the perceptions of AP students on clinical supervision.
The supervisor role is either a consultant physician or a senior clinical nurse (nurse consultant or advanced practitioner, for example as laid out in the university ACP documents and following the HEE supervisory document). We were seeking to determine whether there was informal feedback sought by students and their formal feedback as required by the clinical competency document which must be submitted at the end of each year.

| ME THODS
The aim of this study was to investigate current AP students' experi-

| Study design
A mixed method approach was used to examine AP students' perception with quantitative data collected via an online descriptive crosssectional survey and qualitative data collected via focus groups.

| Setting participant selection
Inclusion criteria: Students currently enrolled on the MSc AP programme at Kings College London, and the exclusion criteria were any student not enrolled in the AP programme. The survey was open to all students enrolled (approximately 145) who were in their first or second year of their studies. With regard to the focus groups, the aim was to hold one to three focus groups, each with approximately 6-10 students.

| Participant recruitment
An announcement was distributed to all currently enrolled AP students via the university AP virtual learning platform. A study information sheet was attached and those interested emailed the Principal Investigator to participate in the focus group. Written informed consent was gained prior to each focus group. For the survey component, a link was supplied in the announcement and consent for the survey was assumed if students completed it online using Microsoft Polls. Participants were made aware that it would not be possible to withdraw data submitted through the online survey portal after submission due to the anonymous submission process. Participants attending a focus group session were informed that it would not be possible to withdraw their recorded data after recording of the session had started, but the participants right to refrain from answering (a) question(s) or leave the focus group event were reiterated to all participants prior to the focus group starting.

| Survey measures
As no previously tested questionnaire was available, the survey was developed through a process of literature review, discussion with members of the target population and members of the author team (Kelley et al., 2003). The survey was developed using best practices and a group consensus on content was gained from all authors. The questionnaire was piloted by the main author with a small number of academics in the Faculty and three alumni who had completed an advanced practice Masters, and feedback was integrated through questionnaire revisions. The final survey contained 5 questions relating to demographics and 11 questions relating to their experience of supervision in clinical practice. Although this was primarily a quantitative section, participants were encouraged to make comments about the answers they had provided.

| Focus groups
Focus group discussions were conducted by two members of the research team as per best practice (Jamieson & Williams, 2003).
One researcher moderated the group discussion, while the second acted as a non-participant observer and note-taker. Data collected at the focus groups were recorded and transcribed. A topic guide was used to encourage participants to reflect on their own experience of clinical supervision and share their views and critically explore clinical supervision. Table 1 presents the topic guide used in the study.

| Data analysis
Quantitative data analysis was undertaken on survey data through the survey platform. Descriptive statistics were used to describe the participant characteristics and their experience of supervision through counts and percentages.
Management of the qualitative data involved interim analysis at the end of each focus group to highlight emerging themes and determine data saturation. Following transcription, audio-recorded data were amalgamated with written field notes. Qualitative data were imported into NVivo (QSR International, 2020) and subjected to a standard process of inductive thematic content analysis (Braun & Clarke, 2013). Final categories and themes were determined using a consensus approach by the authors' team to resolve any differences in interpretation. Anonymised quotes, which highlight key issues of interest, were reported as part of the results. Final themes were agreed using a consensus approach by all members of the project team.
Mixed method integration of data was undertaken using a triangulation design and a convergence model. This involved initial analysis of qualitative and quantitative results in isolation. Following this, results were compared and similarities or contrasting findings were considered together in the final analysis and discussion.

| Survey
A total of 79 students completed the online survey out of 145 AP students equating to a response rate of 55%.
Most respondents were nurses, and other participants were pharmacists (n = 5) and physiotherapist (n = 1) (see Table 2) with 49 in a formal AP trainee role. A total of (n = 42) were funded by Health Education England as each area is given £2500 per student per year for their clinical supervision.
A total of 45 respondents stated they had protected time for their studies, which they described as relating to their formal uni- Respondents were asked about the experience and suitability of their clinical supervisor, and the majority reported that they thought their supervisor had a good understanding of AP and the AP role (n = 66, 84%) and were familiar with the ACP framework (n = 56, 71%) (See Table 3). Over half of respondents thought their workplace colleagues had a good understanding of the role (n = 44, 56%), and similar numbers believed their supervisor did not need to undertake any formal supervisory courses (n = 42, 53%). We asked respondents whether they believed that med- Due to the COVID-19 pandemic, we were unable to undertake further focus groups in March due to lockdown; however, we managed to undertake two focus groups and analyse data on 16 participants.  However, for some AP students, their supervision was less than optimal, and the role not fully understood by their supervisors. For some participants, aligning the AP learning needs with that of medical students helped improve the supervisors understanding: 'I think that the doctors need to take the role more seriously and give us the same attention as they do their medical students. It would also be nice for proper oneon-one time set aside with our mentors as that never seems to happen'.

| Clinical supervisors' preparation for the role
The level of preparation of clinical supervisors was another theme. Educational preparedness for transition from AP trainee to AP has previously been recognised as a major barrier in the literature (Dover et al., 2019). The issue of clinical supervision for transition has highlighted the need for supportive relationships and the need for supervisors during this role transition (Sharrock et al., 2013).
One paper suggests that and having a clinical supervisor, students should have a mentor who supports learning and development of competencies (Murphy & Mortimore, 2020). One solution is use of a clinical internship which ensures the protected time with a clinical supervisor and offers a structured approach to assessment of learning needs in clinical practice (Lee & Fitzgerald, 2008). A hub and spoke model has been proposed for primary care AP training, and the three themes identified were support, supervision and vision (Gloster et al., 2020). Another possibility is increasing the partnerships between higher education and health care (Haggman-Laitila & Rekola, 2014) and undertaking further evaluation of clinical supervision models in advanced practice (Lee & Metcalf, 2009

| CON CLUS ION
The mixed method approach provided adequate new information on issues within the clinical workplace and identified some facilitators and barriers to clinical supervision of AP trainees. It is clear a more coherent approach is required for clinical supervision and an implementation framework that can be formally evaluated including supervision session structure and a standardised documentation tool, which could be directly transferable between different healthcare organisations and universities.

| RELE VAN CE TO CLINI C AL PR AC TI CE
This study was conducted through one university and as such may not be representative of other higher education institutes. However, our students work in a variety of healthcare settings in a metropolitan area in both acute and primary care, and therefore, we believe they are representative of master's students enrolled in AP programmes.
Due to the COVID-19 pandemic, we were unable to undertake further focus groups due to lockdown; however, we managed to undertake 2 focus groups and analyse data on 16 participants.

ACK N OWLED G EM ENTS
Nil.

CO N FLI C T O F I NTE R E S T
Nil.

AUTH O R CO NTR I B UTI O N
GL, EB, CS and MR made substantial contributions to conception and design, or acquisition of data, or analysis and interpretation of data; involved in drafting the manuscript or revising it critically for important intellectual content; given final approval of the version to be published. Each author should have participated sufficiently in the work to take public responsibility for appropriate portions of the content; and agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

DATA AVA I L A B I L I T Y S TAT E M E N T
The authors confirm that the data supporting the findings of this study are available within the article and its supplementary materials.